Medical Suites At Oak Creek (the)
Inspection history, citations, penalties and survey trends for this long-term care facility in Oak Creek, Wisconsin.
- Location
- 2700 Honadel Boulevard, Oak Creek, Wisconsin 53154
- CMS Provider Number
- 525730
- Inspections on file
- 49
- Latest survey
- December 18, 2025
- Citations (last 12 mo.)
- 25
Citation history
Health deficiencies cited at Medical Suites At Oak Creek (the) during CMS and state inspections, most recent first.
Three residents did not receive timely or consistent care as required by physician orders and facility policy. One resident did not have weekly skin assessments or prompt treatment for a new skin impairment, another did not have daily weights or fluid intake consistently monitored despite fluid restriction orders, and a third experienced a delay in urinalysis processing due to labeling errors, resulting in delayed treatment for a UTI.
A resident with multiple risk factors for pressure injuries experienced a decline in health and began refusing dialysis, medications, and meals. Despite these changes, staff did not perform comprehensive skin assessments or update the care plan, and only a toe abrasion was monitored. When the resident was hospitalized, four pressure injuries were identified, and facility records showed no documentation of required weekly skin assessments or care plan revisions during the period of decline.
A resident with heart failure and fluid overload did not receive nine doses of a prescribed eye drop medication because the medication was unavailable and not reordered promptly. The resident, who was cognitively intact and did not refuse care, went several days without the medication, and no follow-up was done to obtain it during that time.
Two residents with recent fractures did not receive their prescribed pain medications due to delays in obtaining valid prescriptions and confusion over accessing the emergency medication supply. Both experienced severe, uncontrolled pain, with one requiring transfer to the ER for pain management. Staff interviews and documentation revealed breakdowns in communication, pharmacy coordination, and adherence to pain management protocols.
The facility failed to maintain proper food safety and sanitation, with milk stored at unsafe temperatures, dirty kitchen and pantry areas, and undated or unlabeled food items found in a pantry refrigerator. An LPN confirmed improper milk temperatures, and a Certified Medication Aide disposed of questionable food. The Food Service Director acknowledged lapses in cleaning schedules, and there was no documentation of required food holding temperatures during meal service.
Surveyors observed that two exterior trash bins near the kitchen, one for recycling and one for trash, were left with lids open and surrounded by debris, including gloves, a mask, and an empty plastic container. The trash bin was also overflowing with trash bags. The FSD acknowledged the issue, the RD did not check the area, and the Administrator stated there was no trash policy. This failure had the potential to affect all 116 residents.
The facility did not develop or implement effective QAPI activities to address repeated deficiencies in food palatability, garbage disposal, and infection control, resulting in ongoing noncompliance. Despite identifying these issues in prior surveys, there were no documented improvement plans or monitoring tools, and the facility did not follow its own QAPI policy.
Several cognitively intact residents reported that their meals were often cold or lukewarm, with complaints documented in resident council notes and confirmed by the RD. Observations showed that food temperatures dropped significantly between preparation and service, resulting in hot foods being served below the expected temperature and cold foods above the recommended range, contrary to facility policy.
Multiple residents experienced prolonged wait times for call light responses, with documented delays often exceeding 20 minutes and sometimes reaching up to 45 minutes. Residents with various medical conditions reported waiting for assistance, including during episodes of incontinence. Staff interviews and call light data confirmed that short staffing and lack of an effective alert system contributed to these delays, and residents expressed concerns about insufficient staff support.
A resident with multiple chronic conditions and moderate cognitive impairment was allowed to self-administer medications without a physician's order or care plan in place. An RN left the resident alone with medications during a medication pass, contrary to facility policy requiring direct observation. Both the RN and DON confirmed that the resident was not authorized for self-administration and that proper supervision was not provided.
Three residents requiring assistance with bathing did not receive scheduled baths or showers, as documented in their records and confirmed by staff and resident interviews. Issues with hot water availability led to missed or substituted bed baths, and some residents were not offered alternative bathing options. The DON was unable to confirm that scheduled bathing occurred and acknowledged the deficiency.
A resident with an abdominal hematoma and moderate cognitive impairment had CBCs performed every two weeks without a physician order being entered into the electronic medical record. Staff interviews revealed confusion over who was responsible for entering lab orders, and the facility lacked a policy on laboratory services.
A resident with severe cognitive impairment and a terminal prognosis did not have complete documentation of required hospice skilled nurse and aide visits, as specified in the hospice plan of care. Staff interviews revealed inconsistent understanding of visit frequency, and the DON confirmed that documentation was missing. The administrator was unable to provide the hospice contract during the survey.
Staff failed to use PPE when entering a contact isolation room for a resident with C. Diff and did not follow proper procedures during medication administration, with a nurse handling pills with bare hands. Additionally, infection control policies were not reviewed or updated annually as required.
A resident with intact cognition and a signed DNR form was incorrectly listed as Full Code in the EMR, with both the Profile tab and a physician's order indicating CPR should be provided. Despite the resident's clear wishes and a DNR bracelet, staff were unaware of the discrepancy, and the process for verifying code status orders was not consistently followed.
A resident who was cognitively intact and transferred to the hospital for GI bleeding did not receive a properly completed Bed Hold/Transfer Notice, and the ombudsman was not notified of the discharge. The required documentation was incomplete, lacking resident signature and transfer details, and there was no evidence that the resident or their representative received the notice. Staff interviews confirmed missing ombudsman notifications for multiple months due to staffing issues.
A resident with a history of depression and behavioral incidents, including threats and aggressive interactions with staff and family, did not have a care plan reflecting her behavioral health needs. Despite staff awareness of these behaviors, no formal interventions or individualized care plan were documented, resulting in a deficiency in comprehensive care planning.
A resident with multiple medical conditions, including advanced wounds and dysphagia, experienced a 19% weight loss in one month. Despite care plan updates noting the weight loss, no new interventions were implemented by the physician or RD, and the DON was unaware of the issue. The resident continued to receive the same supplements and feeding assistance, and the facility did not follow its policy to address significant weight changes.
A resident with COPD who required nebulizer treatments was found to have their nebulizer mask left uncovered on a bedside table, rather than stored in a plastic bag as required by facility policy. Staff confirmed that this did not follow infection control guidelines for respiratory equipment.
A resident with end stage renal disease did not receive consistent assessment and monitoring before and after dialysis treatments, as required by facility policy. Required communication forms were often missing or incomplete, lacking documentation of vital signs, code status, and other key information. Staff reported being unable to complete necessary monitoring due to high workload, resulting in incomplete communication with the dialysis provider.
A resident with multiple chronic conditions did not receive medications at the scheduled times, with some doses administered several hours late. Documentation and interviews revealed that late medication passes were linked to staffing issues, and staff sometimes delayed documentation. The facility's policy required medications to be given within one hour of the scheduled time, but this was not consistently followed.
The facility did not follow current standards for antibiotic stewardship, as antibiotics were prescribed to three residents without adequate documentation of symptoms, laboratory results, or adherence to McGeer's criteria. The facility's infection tracking lacked consistent details on antibiotic use, symptoms, and culture results, and the only policy in place was outdated.
Facility staff did not complete or document neurological checks as required by policy after unwitnessed falls involving two residents with significant medical histories and fall risks. Despite physician orders for neuro checks per protocol, only partial or single assessments were recorded, and required vital signs were sometimes omitted. Staff interviews confirmed the expectation for thorough neuro check documentation, which was not met.
A resident with multiple medical conditions and a history of falls experienced an unwitnessed fall while attempting to ambulate. The facility's required fall investigation was incomplete, with missing documentation and insufficient CNA statements, resulting in a failure to thoroughly investigate the incident and assess the effectiveness of fall prevention interventions.
A resident with arthritis and chronic kidney disease, who required partial assistance with personal hygiene, requested help from a CNA to apply cream to her knees. The CNA refused, physically took the resident's wrist, and placed her hand on her knee instead of assisting, causing the resident to feel threatened and experience wrist soreness. Staff interviews confirmed the incident, which did not align with the facility's zero-tolerance policy for abuse.
A resident who was cognitively intact and required assistance for toileting reported waiting several hours for help after activating her call light, during which a staff member instructed her to use her incontinence brief and did not return. The incident was initially handled as a grievance rather than being reported as neglect, resulting in a delay in notifying the State Agency as required by facility policy.
The facility did not ensure that medications were administered within the required time frame, resulting in a medication error rate of 28.57%. Two residents received multiple medications late, with administration times exceeding the one-hour window allowed by facility policy. Staff interviews and documentation confirmed that the medication orders did not permit a liberalized schedule, and the late administrations were acknowledged as errors.
The facility did not ensure that trash was contained in dumpsters or that the yard was kept sanitary, resulting in ongoing uncontained trash visible from resident windows. Despite expectations for immediate cleanup and closed trash cans, staff left dumpsters open and trash scattered in the area for several days.
A resident with multiple chronic conditions was started on oral vancomycin for presumptive C-diff infection despite the absence of laboratory confirmation and not meeting McGreer's criteria for infection. The resident was not included in the infection surveillance logs, and the DON confirmed that established protocols for antibiotic stewardship and infection identification were not followed.
A resident with multiple complex medical conditions experienced repeated episodes of diarrhea, and a physician ordered a stat C. difficile PCR stool culture. The laboratory test was not completed, as the specimen was never sent to the lab despite ongoing documentation and follow-up. The DON confirmed the test was not performed, which did not meet the facility's policy for laboratory testing as part of its antibiotic stewardship program.
The facility failed to provide written notification of room changes to three residents, as required by their policy. Reviews of the EMRs for these residents revealed no documentation of such notifications. Interviews with staff confirmed the absence of written documentation, despite the facility's policy mandating written notice for room changes.
A resident with moderate cognitive impairment consumed breakfast before a scheduled surgery due to a failure in communication of an NPO order. The dietary department and CNAs were not informed, leading to the delivery of a breakfast tray. The LPN was unaware the resident had eaten before being sent to the hospital, resulting in the surgery's cancellation.
The facility failed to provide an effective training program for agency staff, leading to inconsistent orientation and inadequate preparation for their roles. A resident expressed concerns about the lack of training, particularly on the third shift, affecting their care routine. Interviews with agency staff revealed that the orientation process was informal and inconsistent, with some staff receiving only a brief tour and verbal instructions. The facility's staffing coordinator and DON acknowledged the absence of a formal orientation program, and an orientation checklist was only recently introduced.
Two residents requiring maximum assistance with bathing did not receive scheduled showers, as documented in their care plans. Despite having fully intact cognitive function and not refusing care, one resident reported not having a shower in the last month, while the other was not offered a shower. Facility records corroborated these reports, showing inadequate documentation of bathing activities. The DON and NHA could not provide explanations for the lapses in care.
A resident at risk for pressure ulcers was not provided with the necessary off-loading boots as per their care plan. Despite clear instructions posted in the room, CNAs were unaware of the boot schedule, leading to the resident not wearing the prescribed boots. This oversight was observed during a survey, highlighting a deficiency in care.
A resident with a history of UTIs and sepsis was prescribed Prednisone without an end date, leading to prolonged high doses. The resident experienced low blood pressure, but the facility failed to notify a provider or administer Midodrine as ordered. This oversight resulted in the resident's hospitalization with sepsis and UTI, highlighting the facility's failure to follow policies for notifying changes in condition.
The facility failed to provide adequate care for pressure ulcers in three residents. One resident developed severe pressure injuries due to delayed interventions and lack of a comprehensive care plan. Another resident's air mattress was set incorrectly, potentially affecting their stage 3 pressure injuries. A third resident's wounds were not properly assessed or documented upon admission, leading to inadequate care. These deficiencies highlight significant lapses in pressure ulcer management and documentation.
The facility failed to prevent accidents and provide adequate supervision for residents, resulting in significant harm. A resident with dementia and a history of falls was not provided with individualized interventions, leading to a fall and subsequent death after surgical complications. Another resident suffered a fractured ankle due to improper transfer by CNAs, who did not report the incident immediately. Additionally, a high-risk resident experienced a fall without a proper investigation, indicating systemic issues in fall risk management.
A resident with a history of falls was improperly transferred by two CNAs without using the required mechanical lift, resulting in a fall and a fractured ankle. The incident was not reported to the nurse on duty until hours later, and one CNA made a derogatory comment to the resident, causing anxiety. The facility delayed starting an investigation and did not suspend the CNAs involved, failing to ensure resident safety.
The facility failed to properly dispose of garbage and refuse, with the dumpster observed overflowing and additional garbage bags on the ground. Swarms of flies were noted, and the NHA attributed the issue to challenges in garbage pickup following a change of ownership.
The facility did not ensure that the acting Infection Preventionist (IP), the Director of Nursing (DON), completed specialized training in infection prevention and control. The previous IP left without notice, and the DON, who assumed the role, was still in the process of completing CDC training modules. This deficiency had the potential to affect all 115 residents.
The facility did not ensure that five CNAs had documented performance reviews, despite being employed for over a year. This deficiency was identified during an interview and record review, revealing that CNAs CC, DD, EE, FF, and GG lacked performance evaluations. The facility's policy requires annual evaluations to comply with federal regulations. The NHA confirmed the absence of these evaluations, which could affect all 115 residents receiving care from these CNAs.
The facility failed to provide required written transfer notices to residents and their representatives during hospital transfers. Despite policy requirements, forms lacked necessary details such as contact information for the State Agency and Ombudsman. This issue was observed in multiple cases, including residents with complex medical conditions.
The facility failed to provide required written bed hold notices to residents or their representatives during hospital transfers, affecting four residents. Despite the facility's policy, no documentation was found for residents with serious health conditions, highlighting a systemic issue in compliance with notification requirements.
The facility failed to label and store medications according to policy, with surveyors finding unlabeled and expired medications on two medication carts and in a medication room. Specific instances included unlabeled lantus insulin and lantanoprost eye drops, as well as expired stock medications.
The facility failed to maintain effective infection control, as staff did not adhere to PPE protocols for residents with infections. A resident with COVID-19 was not consistently managed with proper PPE, and another resident suspected of C-diff was not promptly isolated. Additionally, the 300 unit linen cart was observed uncovered, contrary to policy.
A resident with moderate impairment and dependency on mechanical lift transfers was verbally abused and neglected by two CNAs, resulting in a fall and fractured ankle. The CNAs did not use the required equipment and failed to report the incident immediately, delaying medical evaluation. The facility's investigation confirmed the neglect and verbal abuse, with the resident experiencing increased pain and emotional distress.
The facility failed to promptly report two abuse allegations involving residents. One resident was transferred without a mechanical lift, resulting in a fall and a fractured ankle, and was subjected to derogatory remarks by a CNA. This incident was not reported to the NHA or LPN immediately, nor to the state agency within the required timeframe. Another resident's abuse investigation results were submitted late to the State Survey Agency due to ownership transition issues. The facility did not adhere to its policy on immediate reporting of abuse allegations.
The facility failed to provide adequate assistance with activities of daily living for several residents, leading to deficiencies in nutrition, grooming, and hygiene. A resident with Parkinsonism was not set up for meals and left in a wet bed for hours, while another resident reported not receiving a shower in four weeks. Additionally, a resident with a neurocognitive disorder was observed with long, dirty fingernails, indicating a lack of proper grooming care.
A resident, who is bed-bound and legally blind, reported feeling bored with nothing to do but watch TV. The facility failed to complete an activity assessment or develop a plan of care to provide individualized and meaningful activities. Despite the resident's severe cognitive impairment and highly impaired vision, the facility did not offer suitable activities, and the activity evaluation forms were incomplete.
Failure to Provide Timely and Consistent Care, Monitoring, and Treatment
Penalty
Summary
Three residents did not receive necessary care and treatment as required by physician orders, facility policy, and their individual care plans. One resident with chronic kidney disease, diabetes, and a history of pressure injuries did not have weekly skin assessments completed for three weeks. When a new skin impairment was observed, there was no comprehensive assessment, no treatment initiated, and no care plan revision at the time the issue was first identified. Documentation was inconsistent, and the wound was not properly classified or communicated to all relevant parties until several days later. Another resident with heart failure and fluid overload had physician orders for daily weights and strict fluid intake monitoring. However, fluid intake was not consistently documented, with many days missing numerical values or any record at all. Daily weights were also not consistently recorded, and staff interviews revealed a lack of clarity and compliance with documentation procedures. The resident's care plan and Kardex did not consistently reflect the fluid restriction order, and staff were not always aware of or following the monitoring requirements. A third resident with a urinary tract infection and pressure ulcer had a urinalysis ordered, but the specimen was not processed for over a week due to improper labeling. This resulted in a delay in diagnosis and treatment, as the antibiotic was not ordered until after the test was finally completed. Staff interviews confirmed that the labeling error and lack of timely communication with the laboratory led to the delay in processing the specimen and initiating appropriate treatment.
Failure to Assess and Monitor Skin Integrity in High-Risk Resident
Penalty
Summary
A deficiency occurred when the facility failed to comprehensively assess and monitor the skin condition of a resident who was at high risk for pressure injuries. The resident had multiple diagnoses, including End Stage Renal Disease requiring dialysis, Diabetes Mellitus, and severe calorie malnutrition, all of which increased their risk for pressure injuries. Despite these risk factors and a documented decline in the resident's health status, the facility did not update the plan of care or conduct additional skin assessments when the resident began refusing dialysis, medications, and meals. The last documented licensed nurse skin assessment was completed several weeks prior to the resident's significant health decline. The facility's policy required regular skin assessments and updates to the care plan when a resident's condition changed, but these were not performed. Staff interviews revealed that the wound care nurse only assessed a toe abrasion and did not examine other areas of the resident's body, including the heels or hips. Other staff members, including the nurse manager and nurse practitioner, acknowledged that no comprehensive skin assessment was conducted during the period of the resident's decline, despite increased refusals of care and a need for greater assistance with activities of daily living. When the resident was eventually transferred to the hospital, emergency department documentation and photographs identified four pressure injuries, including unstageable injuries to the hip and back, a stage 1 injury to the ischium, and a deep tissue injury to the heel. Facility records lacked documentation of weekly skin assessments or any revisions to the plan of care in response to the resident's deteriorating condition and increased risk factors. Interviews with facility staff confirmed that no additional skin assessments were performed during this critical period.
Missed Medication Doses Due to Unavailability and Lack of Follow-Up
Penalty
Summary
A deficiency occurred when a resident with diagnoses including heart failure and fluid overload did not receive nine doses of an ordered eye drop medication, Tetrahydrozoline solution, over a period of several days. The resident, who was cognitively intact and did not refuse care, reported to the surveyor that the eye drops were not administered for almost a week. Review of the Medication Administration Record confirmed that the medication was not given from 11/26/2025 to 11/30/2025 due to the medication being unavailable and not reordered in a timely manner. No follow-up was conducted to ensure the medication was obtained during this period.
Failure to Provide Timely and Appropriate Pain Management
Penalty
Summary
The facility failed to provide safe and appropriate pain management for two residents who required such services, resulting in harm. One resident was admitted following hospitalization for multiple fractures and had a history of pain, anxiety, and depression. Upon admission, this resident did not receive prescribed pain medications due to issues with obtaining valid prescriptions from the hospital and delays in entering the resident into the pharmacy system. The resident experienced severe, uncontrolled pain and was ultimately sent back to the emergency room for pain management. Documentation showed that the resident's pain was not adequately addressed upon arrival, and staff were unable to access the facility's emergency medication supply due to the lack of valid prescriptions and authorization codes from the pharmacy. Another resident was admitted with a fracture and had orders for multiple pain medications, including Roxicodone, Tramadol, and acetaminophen. Despite these orders, the resident did not receive the prescribed narcotic pain medications because the scripts were not received by the pharmacy in a timely manner. Staff administered acetaminophen for pain, but there was inconsistent documentation of pain assessments and medication administration. The resident reported severe pain and repeatedly stated that prescribed pain medications were not available. Staff interviews revealed confusion about the process for obtaining and administering narcotic medications from the emergency supply, and the resident's pain was not effectively managed until the correct medications were finally delivered and administered. In both cases, the facility's failure to ensure timely receipt and administration of prescribed pain medications, as well as inadequate communication and documentation, led to residents experiencing unnecessary pain. The facility's own pain management policy required prompt evaluation and intervention for pain, but these procedures were not followed, resulting in harm to the residents involved.
Food Safety and Sanitation Deficiencies in Kitchen and Pantry
Penalty
Summary
The facility failed to ensure proper food safety and sanitation practices in several key areas. Observations revealed that milk gallons were repeatedly stored on the counter in the 300-hall dining room without refrigeration or ice, resulting in milk temperatures above the required 41 degrees Fahrenheit. These findings were confirmed by an LPN who verified the elevated temperatures after meal service. Additionally, the pantry refrigerator in the 400-hall was found to be dirty, containing undated and unlabeled food items, including sandwiches and a brown liquid in an ice tray. The Certified Medication Aide acknowledged the unsanitary conditions and disposed of the questionable food items during the survey. Further inspection of the main kitchen uncovered significant cleanliness issues. The floor beneath equipment such as the hot plate warming storage system and oven was dirty with food debris and grime. The sandwich station, ice machine, and walls behind sinks and food stations were also found to be unclean, with food spatter and brown stains present. The Food Service Director admitted that some areas had not been cleaned for about a month and that certain surfaces, like the walls, were not included in the cleaning schedule. Drinking glasses were observed to have a hard water film, and the director was unsure how to remove these stains. Review of facility records and interviews revealed that there was no documentation of hot holding temperatures for food on the tray line, as required by policy and the FDA Food Code. The staff only recorded cooking temperatures and did not monitor or document holding temperatures during food service. The Registered Dietitian confirmed ongoing issues with kitchen and pantry cleanliness and stated that the kitchen was responsible for monitoring the pantry refrigerator. The facility lacked policies or schedules for cleaning key kitchen areas and for checking food temperatures throughout food service, contributing to the deficiencies observed.
Improper Management of Exterior Trash Area
Penalty
Summary
The facility failed to ensure proper disposal of garbage and refuse in the exterior trash area, as observed during a survey. Two trash bins located outside near the kitchen, one for recycling and one for trash, were found with all lids open and surrounded by trash debris, including gloves, a mask, and an empty plastic container. The trash bin designated for trash was also overflowing with trash bags. The Food Service Director acknowledged that the lids should have been closed and the debris cleaned, noting that dietary staff took out the trash after each meal. The Registered Dietitian stated she did not check the trash area, and the Administrator confirmed there was no policy in place for trash management. All 116 residents in the facility had the potential to be affected by this deficiency, as the improper management of the trash area could contribute to pest infestation. No specific residents or their medical conditions were mentioned in the report.
Failure to Implement QAPI Process for Repeated Deficiencies
Penalty
Summary
The facility failed to develop and implement an effective Quality Assurance and Performance Improvement (QAPI) process to address previously identified deficient practices, resulting in continued noncompliance. During a survey, it was found that the facility had been cited for deficiencies related to food palatability, proper garbage/refuse disposal, and infection prevention and control in a prior survey, and these same issues were cited again in a subsequent survey. The Administrator acknowledged that while survey results were used to identify areas needing improvement, the facility had not developed or implemented performance plans for these deficiencies. Specifically, there were no metrics or monitoring tools for food palatability, garbage disposal issues were not revisited or addressed with new corrective measures, and infection control improvements were limited to education on enhanced barrier precautions without broader performance improvement projects. Review of the facility's QAPI policy indicated that all identified problems should be addressed and prioritized, with actions documented and monitored through QAA Committee meetings. However, interviews and record reviews revealed that the facility did not follow its own policy, as there was a lack of documented improvement plans and ongoing monitoring for the cited deficiencies. This failure to act on identified problems through the QAPI process led to repeated citations for the same issues affecting all residents in the facility.
Failure to Serve Palatable Food at Safe and Appetizing Temperatures
Penalty
Summary
The facility failed to ensure that food was palatable and served at a safe and appetizing temperature for five cognitively intact residents. Multiple residents reported that their meals were often cold or lukewarm, with some noting that changes in the kitchen or delivery system had resulted in more frequent cold meals. Resident council notes also documented complaints about milk sitting out all day and food being cold due to delayed delivery. These concerns were corroborated by interviews with residents and the Registered Dietitian, who confirmed an increase in complaints about cold food and the absence of a pellet system to keep food hot. Direct observations of meal service revealed that while food temperatures were within appropriate ranges when initially prepared in the kitchen, significant drops in temperature occurred by the time meals were served. For example, a test tray plated and placed on a cart showed hot food items dropping below the expected 130 degrees Fahrenheit by the time they were served, with cold items also exceeding the recommended temperature. The facility's policy required food to be served at safe and appetizing temperatures, but the observed practices and resident feedback indicated this standard was not consistently met.
Delayed Call Light Response for Multiple Residents
Penalty
Summary
The facility failed to ensure timely response to call lights for five out of 46 residents, resulting in prolonged wait times for assistance. Multiple residents reported and were observed experiencing significant delays, with call light response times documented as exceeding 20 minutes on several occasions, and in some cases, reaching up to 45 minutes. Staff interviews confirmed that call lights were not always answered promptly, particularly during periods of short staffing or when staff were engaged in other duties such as passing meal trays. Observations revealed that staff sometimes walked past illuminated call lights without responding, and that there was no pager system in place to alert staff to active call lights outside of the nurses' station. Residents affected by these delays included individuals with various medical conditions such as femur fracture, asthma, muscle weakness, urinary tract infection, chronic kidney disease, diabetes, sepsis, prostate cancer, repeated falls, end stage renal disease, and others. Some residents were cognitively intact, while others had moderate cognitive impairment. Residents described waiting over an hour for assistance, including instances where they remained in soiled conditions due to incontinence until staff responded. Call light data reports corroborated these accounts, showing multiple instances of extended response times across different dates and shifts. Staff interviews indicated that the unit was often staffed with only one CNA, which was insufficient to meet the needs of residents with high medical acuity and complex care requirements. Staff acknowledged that all personnel were expected to respond to call lights, but this expectation was not consistently met. The DON stated that response times exceeding 20 minutes were not acceptable, yet documented response times frequently surpassed this threshold. Resident Council notes further reflected resident concerns about insufficient staff assistance and infrequent rounding.
Failure to Assess and Supervise Resident Self-Administration of Medications
Penalty
Summary
A resident with diagnoses including congestive heart failure, chronic obstructive pulmonary disease, hypertension, and left arm pain was readmitted to the facility and assessed as moderately cognitively impaired, with a BIMS score of 11 out of 15. The resident did not have a care plan for self-administration of medications, nor was there a physician's order permitting self-administration documented in the electronic medical record. Despite this, during a medication pass, an RN prepared the resident's medications, placed them in a medicine cup, and left the room to retrieve additional Tylenol, leaving the resident unobserved with the medications. The resident then self-administered the medications without direct nurse supervision. Interviews with the RN and the Director of Nursing confirmed that the resident was not authorized to self-administer medications and that facility policy requires nurses to observe residents taking their medications. Review of facility policies further indicated that self-administration must be assessed and documented, and that medication administration should be directly observed by nursing staff. These actions and omissions resulted in a failure to ensure the resident was safe to self-administer medications and that medication administration was properly supervised and documented.
Failure to Provide Scheduled Baths or Showers Due to Facility Water Issues
Penalty
Summary
The facility failed to provide scheduled baths or showers to three residents who required assistance with bathing, as evidenced by documentation and interviews. One resident with end stage renal disease, diabetes, and other conditions did not receive weekly baths or showers on multiple occasions, as shown in the electronic medical record. This resident was cognitively intact and required substantial to maximum assistance for bathing. The resident reported that there was no hot water and no showers available. Another resident with a history of fractures, dialysis dependence, and anxiety also did not receive weekly baths or showers as scheduled, with documentation showing missed bathing dates and substitution of bed baths due to lack of hot water. Staff interviews confirmed that some rooms lacked hot water, requiring alternative bathing methods such as basin baths or using water from other sources. The DON was unable to confirm whether showers or baths had occurred as scheduled for this resident. A third resident, admitted after fractures and requiring maximum assistance with bathing, reported feeling dirty and having received only one bed bath since admission, with no hair washing. Documentation confirmed the absence of showers or bed baths for this resident during the review period. Staff interviews revealed that the resident had not been offered a bath or shower, and that cold water in the shower room led most residents to choose bed baths, though this resident had not been offered one. The DON stated there was no reason for the missed baths or showers and expected staff to follow the bathing schedule and resident preferences.
Lab Tests Performed Without Physician Order
Penalty
Summary
A failure occurred in the facility when laboratory tests were obtained for a resident without a physician order. The resident, who was readmitted with an abdominal hematoma and had moderate cognitive impairment, was supposed to have CBCs performed every two weeks to monitor her condition, as discussed between the unit manager and the nurse practitioner. However, review of the electronic medical record revealed that no physician orders for these CBCs were entered, even though the laboratory tests were performed as scheduled. Interviews with facility staff indicated that there was confusion regarding responsibility for entering orders into the electronic system, with the nurse practitioner stating she did not have access to enter orders and the unit manager and DON indicating that nurses are responsible if providers do not enter them. Additionally, the facility did not have a policy on laboratory services. This lack of a documented physician order prior to obtaining laboratory tests had the potential to result in unnecessary laboratory testing for residents.
Failure to Collaborate and Document Hospice Services
Penalty
Summary
The facility failed to collaborate care with the hospice agency for a resident who was receiving hospice services. The resident, who had chronic obstructive pulmonary disease and dementia with severe cognitive impairment, was readmitted to the facility and had a care plan indicating a terminal prognosis and the need for hospice services. The hospice plan of care specified that the resident was to receive visits from a skilled nurse and a home hospice aide twice a week. However, documentation in the hospice binder showed missing records for skilled nurse visits during two separate weeks and incomplete documentation for home hospice aide visits, with some weeks lacking evidence of the required two visits. Interviews with staff revealed that the LPN believed the aide and nurse each visited once a week unless there was a change in condition, at which point additional visits would be requested. The DON stated that the unit manager was responsible for obtaining hospice visit documentation but acknowledged that supporting documentation for the visits was not available, despite the belief that visits had occurred. The administrator was unable to provide a copy of the hospice contract during the survey, as it could not be located and the hospice agency was unavailable after hours.
Infection Control Failures in PPE Use, Medication Handling, and Policy Review
Penalty
Summary
The facility failed to adhere to infection prevention and control protocols in several instances. One incident involved a staff member, the Director of Maintenance, entering a contact isolation room of a resident diagnosed with Clostridium difficile (C. Diff) without donning the required personal protective equipment (PPE). The staff member touched surfaces within the room, including the overbed table and the footboard of the resident's bed, with bare hands. The staff member later acknowledged not noticing the contact isolation signage and not wearing PPE as required. Facility policy specifies that staff must wear gloves and gowns when entering rooms under contact precautions, particularly for infections such as C. Diff. Another deficiency was observed during medication administration, where a registered nurse poured oral medications directly into her bare hands before placing them into a medicine cup and handing them to a resident. The nurse admitted to sanitizing her hands beforehand but recognized that medications should not be handled with bare hands. Facility policy requires that medications be dispensed without direct hand contact. Additionally, the facility failed to review and/or revise key infection control policies, such as those related to antibiotic stewardship and transmission-based precautions, on an annual basis as required by their own protocols.
Failure to Accurately Reflect Resident Code Status in EMR
Penalty
Summary
The facility failed to ensure that a resident's code status was accurately reflected in the electronic medical record (EMR). Upon admission, the resident, who had diagnoses including depression, anxiety, and bipolar disorder and demonstrated intact cognition, signed a form electing Do Not Resuscitate (DNR) status. However, the EMR Profile tab and a physician's order both incorrectly indicated that the resident was to receive cardiopulmonary resuscitation (CPR), designating her as Full Code. Multiple staff interviews confirmed the discrepancy between the resident's documented wishes and the information in the EMR. The admitting nurse completed the Code Status Form with the resident, who clearly expressed a desire for no CPR, and the resident wore a DNR bracelet. Despite this, the order for CPR was entered into the EMR, and staff were unaware of the inconsistency. The Director of Nursing acknowledged that the process for verifying code status orders was not consistently followed, as staff were expected to refer to the completed Code Status Form and double-check the information entered into the EMR. The facility's policy required clear documentation of advance directives in designated sections of the medical record, but this was not adhered to in this instance.
Failure to Notify Ombudsman and Provide Proper Bed Hold/Transfer Notice
Penalty
Summary
The facility failed to notify the ombudsman of resident discharges and did not provide a transfer notice and bed hold policy to the resident and/or resident representative for one of three residents reviewed for discharges. Specifically, for a resident admitted with thrombocytopenia and anemia, who was cognitively intact, the documentation related to their transfer to the hospital for gastrointestinal bleeding was incomplete. The Bed Hold/Transfer Notice form was not properly filled out, lacking details about the reason and destination for the transfer, and was not signed by the resident, only by the nurse. There was also no evidence that the resident or their representative received a copy of the notice. Interviews with facility staff revealed that ombudsman notifications for discharges were missing for the months of July and August, with only September notifications available. The Director of Nursing and Social Worker confirmed the absence of required notifications, attributing it to staffing vacancies. The facility's policy requires that a signed and dated copy of the bed-hold notice be provided to the resident or representative and kept in the medical record, but this was not followed in the reviewed case.
Failure to Develop and Implement Behavioral Health Care Plan
Penalty
Summary
The facility failed to ensure that a comprehensive care plan was developed and implemented to address the behavioral health needs of a resident with diagnoses including fibromyalgia, morbid obesity, and depression. Although the resident demonstrated intact cognition and did not initially exhibit mood or behavioral symptoms upon admission, subsequent interviews and record reviews revealed multiple incidents of behavioral issues. These included the resident making accusatory statements, threatening staff, requesting not to work with certain CNAs, and engaging in loud, aggressive interactions with staff and family members in the facility lobby. Staff members, including the DON, Unit Manager, and Social Worker, acknowledged awareness of these behaviors but confirmed that no specific behavioral interventions or care plan addressing these issues had been put in place. Despite facility policies requiring the assessment and care planning of behavioral health needs, the care plan for this resident did not reflect her behavioral symptoms or outline measurable interventions. Staff responses to the resident's behaviors were informal and inconsistent, such as having another staff member present during interactions or reassigning CNAs, rather than being part of a documented, individualized care plan. The lack of a formalized care plan addressing the resident's behavioral health needs constituted a deficiency in meeting regulatory requirements for comprehensive, person-centered care planning.
Failure to Address Significant Weight Loss in Resident with Complex Medical Needs
Penalty
Summary
A significant deficiency occurred when the facility failed to address a 19% weight loss in one month for a resident with multiple complex medical conditions, including Parkinson's disease, dementia, diabetes, dysphagia, and several advanced pressure ulcers. The resident was admitted and re-admitted to the facility, and her care plan identified her as being at nutritional risk due to wound infection, dysphagia, and increased nutritional needs for wound healing. Despite these risks and a documented significant weight loss, the care plan was only revised to note the weight loss, without adding new or revised interventions to address the issue. The resident's weight dropped from 154.1 lbs to 124 lbs over a one-month period, as confirmed by multiple re-weighs. The care plan approaches included monitoring for signs of malnutrition and significant weight loss, providing supplements, and ensuring total assistance with feeding. However, when the significant weight loss was identified, neither the physician nor the registered dietician implemented new interventions. The registered dietician acknowledged the weight loss and stated that no additional measures were put in place, citing limited options and the absence of a fortified foods program. The director of nursing was unaware of the weight loss and stated that she would have expected new interventions to be implemented. Throughout this period, the resident continued to receive the same supplements and assistance with feeding, and her oral intake was documented as adequate. Despite this, the significant weight loss was not addressed with additional interventions, and the facility's policy requiring action in response to significant weight changes was not followed. The deficiency was identified through interviews, record reviews, and policy review, which confirmed that the facility failed to take appropriate action to maintain the resident's nutritional status.
Improper Storage of Nebulizer Mask Breaches Infection Control
Penalty
Summary
A deficiency was identified when a resident with chronic obstructive pulmonary disease (COPD) was observed to have their nebulizer mask stored improperly. The resident, who was moderately cognitively impaired, had a physician's order for Ipratropium-Albuterol inhalation solution to be administered via nebulizer as needed for shortness of breath or cough. During two separate observations, the nebulizer mask was found lying uncovered on the bedside table, rather than being stored in a plastic or Ziploc bag as required by facility policy and infection control guidelines. Staff interviews confirmed that the mask should have been stored in a plastic bag when not in use. The registered nurse, unit manager, and infection preventionist all acknowledged that the observed storage method did not comply with the facility's policy, which specifically directs that nebulizer masks and mouthpieces be stored in a Ziploc bag. This failure to follow proper storage procedures for respiratory equipment constituted a breach of infection control practices.
Failure to Ensure Ongoing Assessment and Communication for Dialysis Care
Penalty
Summary
The facility failed to ensure ongoing assessment and monitoring for complications before and after dialysis treatments for a resident with end stage renal disease who was dependent on hemodialysis. The resident's care plan required monitoring and documentation of signs and symptoms related to renal insufficiency and dialysis complications, as well as communication with the dialysis facility using a designated Dialysis Communication Form. However, review of the electronic medical record and interviews revealed that these forms were either missing or incompletely filled out for multiple dialysis sessions. Specifically, only one form was found in the facility records, and it was largely incomplete, missing documentation on vital signs, code status, blood glucose, food intake, cognitive orientation, pain, and changes in condition. Another form located by dialysis staff was also incomplete, lacking the pre-dialysis weight. The dialysis registered nurse confirmed that the facility staff were responsible for completing the pre-dialysis section but did not always do so, and the forms were not consistently uploaded into the system as required. Additionally, an LPN reported that due to high unit traffic and frequent admissions or discharges, she was not always able to complete the dialysis communication report or monitor the resident's vital signs as required. Facility policy mandated thorough communication with the dialysis facility, including timely medication administration, vital signs, code status, nutrition/fluid management, and documentation of dialysis treatment and resident response. The lack of consistent and complete documentation and communication between the facility and the dialysis provider constituted a failure to follow policy and ensure safe, appropriate dialysis care for the resident.
Failure to Administer Medications Timely for a Resident
Penalty
Summary
The facility failed to ensure timely administration of medications for one resident, as required by policy and physician orders. Record review and interviews revealed that the resident, who had diagnoses including end stage renal disease, type 2 diabetes, ascites, amputation, and sleep apnea, did not consistently receive medications at the scheduled times. The resident reported receiving medications due at 7:00 AM as late as 9:40 AM, and evening medications up to 45 minutes late. Documentation confirmed multiple instances where medications were administered between two hours and 48 minutes to five hours and 48 minutes after the scheduled times. Medications affected included melatonin, pantoprazole, rifaximin, sertraline, and atorvastatin. Staff interviews indicated that late medication passes were related to staffing issues. The DON stated that the expectation was for medications to be administered within one hour before or after the scheduled time, in accordance with facility policy. However, it was observed that nurses sometimes documented medication administration at the end of the day rather than immediately after administration, making it unclear if the documentation accurately reflected the actual administration times. The facility's policy required medications to be administered within 60 minutes of the scheduled time unless otherwise ordered by a physician.
Failure to Implement Effective Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement an Antibiotic Stewardship Program that adhered to current standards of practice for prescribing antibiotics, as evidenced by the review of three residents' records. For one resident with a diagnosis of malignant neoplasm of the spinal cord, antibiotics were prescribed for urinary symptoms without supporting laboratory results or documentation of symptoms consistent with McGeer's criteria for urinary tract infection (UTI). The Infection Preventionist (IP) confirmed the absence of lab results and appropriate documentation, making it impossible to verify the necessity or appropriateness of the antibiotic prescribed. Another resident, admitted with malignant neoplasm of the kidney and chronic obstructive pulmonary disease, was prescribed antibiotics following a urinalysis that showed abnormal findings. However, there was no documentation in the nurses' notes regarding the resident's symptoms or the rationale for ordering the urinalysis. The IP confirmed that this case also did not meet McGeer's criteria due to the lack of documented symptoms prior to testing. Additionally, the urine culture later revealed the presence of two organisms, one of which was not susceptible to the prescribed antibiotic. A third resident, with type two diabetes mellitus, returned from the emergency room with an order for antibiotics for a urine infection, but there was no laboratory evidence or documentation of symptoms to support the need for antibiotics. The facility's infection tracking documentation lacked consistent information on whether infections met McGeer's criteria, details of antibiotic use, signs or symptoms, and culture results. The Director of Nursing stated that the expectation was for nurses to follow updated policy and document appropriately, but the only policy provided was outdated and did not ensure compliance with current standards.
Failure to Complete Neurological Checks After Unwitnessed Falls
Penalty
Summary
Facility staff failed to complete neurological checks in accordance with facility policy and procedure for two residents who experienced unwitnessed falls. The facility's policy required specific neurological assessment protocols, including frequent monitoring and documentation of vital signs and neurological status after any unwitnessed fall or suspected head injury. Despite these requirements, documentation revealed that neurological checks were either incomplete or missing for both residents following their respective falls. One resident, with a history of stroke, altered mental status, abnormal gait, and previous falls, experienced an unwitnessed fall. The resident was found on the floor without apparent injury, and the physician assistant ordered neuro checks per facility protocol. However, only a few neuro checks were documented, and not all included vital signs as required. The documentation did not reflect completion of the full neuro check schedule outlined in the facility's policy. Another resident, with diagnoses including congestive heart failure, kidney failure, diabetes, muscle weakness, and a history of falls, also experienced multiple unwitnessed falls. In each instance, the physician ordered neuro checks per protocol, but documentation showed that only one or a few neuro checks were completed, with significant gaps in the required monitoring schedule. Interviews with staff confirmed that neuro checks should have been performed and documented according to the established protocol, but this was not done.
Failure to Thoroughly Investigate Resident Fall
Penalty
Summary
A deficiency occurred when the facility failed to ensure adequate supervision and assistance to prevent accidents for a resident with a history of falls and multiple medical conditions, including congestive heart failure, kidney failure, diabetes mellitus, muscle weakness, and abnormal gait. The resident, who was cognitively intact and required supervision and assistance for transfers and mobility, experienced an unwitnessed fall in their room. The resident was found on the floor between the bed and the wall, with a minor injury to the right finger, and reported attempting to ambulate but could not recall if an assistive device was used at the time. The facility's policy required thorough investigation and documentation of all incidents and accidents, including falls, with specific instructions for staff to complete incident reports, document all pertinent information, and identify root causes. However, the fall investigation packet for this incident was incomplete, with missing information such as the date and time of the fall, staff present or who found the resident, and details about the resident's activities and interventions prior to the fall. Statements from involved CNAs were either missing or inadequately completed, with many questions left blank or marked as not applicable, and no statement was obtained from the CNA assigned to the resident at the time of the fall. Interviews with facility staff confirmed that the expected protocol was not followed, as all areas of the fall packet should have been thoroughly completed. The Director of Nursing acknowledged that the investigation was not thorough. The lack of a complete and thorough investigation meant that key information about the circumstances of the fall and the effectiveness of fall prevention interventions was not obtained.
Failure to Protect Resident from Physical Abuse During Care Request
Penalty
Summary
The facility failed to protect a resident from physical abuse as required by its policies. A cognitively intact resident with arthritis and chronic kidney disease requested assistance from a CNA to apply cream to her knees. The CNA refused to assist, stating the resident could do it herself, and then physically took the resident's wrist and placed her hand on her knee. The resident reported feeling threatened and experiencing soreness in her wrist after the incident. Multiple staff interviews confirmed that the CNA physically guided the resident's hand to her knee instead of providing the requested assistance. The facility's policy mandates zero tolerance for abuse, neglect, and exploitation, and requires staff to assist residents with tasks they are unable to perform independently. Despite the resident's need for partial assistance with personal hygiene, the CNA did not provide the requested help and instead engaged in physical contact that the resident perceived as threatening. The incident was reported by staff, and the resident confirmed feeling safe in the facility overall, but identified this as an isolated event where she felt threatened and experienced discomfort.
Failure to Timely Report Allegation of Neglect
Penalty
Summary
The facility failed to timely report an allegation of neglect involving a resident who was cognitively intact and required partial to moderate assistance for toileting hygiene. The resident reported that she had activated her call light at 5:00 AM to request assistance to use the bathroom, but after waiting for an hour, a staff member told her to use the bathroom in her incontinence brief and did not return. The resident ultimately received assistance around 8:00 AM when her spouse arrived. This incident was documented in the facility's grievance summaries. The Director of Hospitality initially treated the incident as a grievance and submitted it as such on the same day, without recognizing it as potential neglect. The Administrator in Training later determined that the incident should have been reported to the State Agency as neglect, but this was not done until several days after the event. The delay in reporting the allegation of neglect was confirmed through interviews and review of facility documentation, indicating a failure to follow the facility's policy requiring immediate reporting of such incidents.
Medication Administration Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication administration error rate below 5%, as required. During observations, Nurse Manager 2 administered medications to two residents outside the prescribed time window. For one resident, medications including pregabalin, folic acid, tamsulosin, and vitamin B1, which were scheduled for 9:00 AM, were given at 10:29 AM and 10:30 AM. For another resident, medications such as amlodipine, clopidogrel, sucralfate, and pantoprazole, also scheduled for 9:00 AM, were administered at 10:38 AM. The facility's medication audit confirmed these times, and the medication orders did not allow for a liberalized medication pass schedule. Interviews with the Nurse Manager and the Director of Nursing confirmed that, per facility policy, medications must be administered within one hour before or after the scheduled time unless otherwise specified. The observed late administrations were acknowledged as errors. Review of the facility's policy on medication administration emphasized adherence to the six rights of medication administration, including the right time, which was not followed in these instances. As a result, eight errors were identified out of 28 opportunities, resulting in a medication error rate of 28.57%.
Failure to Maintain Sanitary Dumpster and Yard Conditions
Penalty
Summary
The facility failed to maintain the dumpster area and surrounding yard in a sanitary condition, resulting in uncontained trash being present over multiple days. Observations revealed that dumpsters were frequently left open, and trash such as blue exam gloves, plastic bags, bottles, pop cans, Styrofoam cups, and plastic clam shells were scattered on the ground, cement, grassy areas, and in shrubs. These conditions were visible from resident windows and persisted despite multiple observations at different times of day. During an interview, the Maintenance Director confirmed the ongoing presence of trash and stated that trash pickup was only attempted once a week and had not been done recently due to cold weather. The General Manager acknowledged that the expectation was for trash cans to remain closed and for any fallen trash to be picked up immediately, but this was not being followed. No information about specific residents or their medical conditions was provided in the report.
Antibiotic Initiated Without Justification or Laboratory Confirmation
Penalty
Summary
A resident with multiple complex medical diagnoses, including immunodeficiency, type II diabetes, end stage renal disease with dialysis, and thrombocytopenia, experienced ongoing diarrhea following dialysis. Despite the presence of symptoms, laboratory testing for Clostridium difficile (C-diff) was not completed as the lab did not receive the necessary stool samples, and results were not obtained. Nevertheless, an order was given to start oral vancomycin for presumptive C-diff infection without laboratory confirmation or meeting the facility's established McGreer's criteria for C-diff infection. The resident was not listed on the facility's infection surveillance logs for C-diff infection, nor was the administration of vancomycin documented in these logs. Interviews with the DON confirmed that the resident did not meet the criteria for C-diff infection and that the facility's expectation was to follow McGreer's criteria for infection identification and antibiotic use. The facility's policy requires adherence to antibiotic stewardship protocols, including laboratory confirmation and use of established criteria before initiating antibiotics, which was not followed in this case.
Failure to Complete Physician-Ordered Laboratory Testing for Antibiotic Use
Penalty
Summary
A deficiency occurred when the facility failed to provide physician-ordered laboratory testing for a resident who was being monitored for antibiotic use. The resident, who had multiple complex medical diagnoses including immunodeficiency, type II diabetes, end stage renal disease with dialysis, and thrombocytopenia, experienced multiple episodes of diarrhea following dialysis. Orders were given to obtain a stat C. difficile PCR stool culture to assist in diagnosis and treatment. Despite these orders, the laboratory test was not completed. Progress notes indicated ongoing waiting for the collection and results, and subsequent documentation revealed that the laboratory had not received the order or the stool sample. Interviews with the DON confirmed that the specimen was never sent to the laboratory, and the facility's policy required laboratory testing to be performed in accordance with current standards of practice. This failure resulted in the ordered laboratory test not being performed for the resident.
Failure to Provide Written Notification of Room Changes
Penalty
Summary
The facility failed to provide written notification of room changes to three residents, as required by their policy. The policy, dated 03/07/23, mandates that residents receive written notice of room changes, including the reasons for the move. However, reviews of the electronic medical records (EMR) for three residents revealed no documentation of such notifications. Specifically, one resident had a room change on 12/03/24, another on 11/23/24, and the third on 11/14/24, but none had written notifications documented in their EMRs. Interviews with the Social Worker, Administrator, and Director of Nursing confirmed the absence of written documentation in the residents' EMRs. The Administrator stated that the expectation was for staff to document room changes in the EMR progress notes and to place written notifications under the MISC tab in the EMR. This deficiency was identified during a review of 17 sample residents.
Failure to Implement NPO Order Leads to Surgery Cancellation
Penalty
Summary
The facility failed to implement a physician's order for a resident to be Nothing by Mouth (NPO) prior to a scheduled surgery. The resident, who had moderate cognitive impairment, consumed breakfast before being transferred to the hospital, resulting in the cancellation of his hip surgery. The resident's wife expressed her distress over the situation, emphasizing the need for better communication among the nursing staff to prevent such incidents. The deficiency occurred because the dietary department was not informed of the NPO order, leading to the delivery of a breakfast tray to the resident. Additionally, the Certified Nurse Aides (CNAs) were not made aware of the NPO order, and the Licensed Practical Nurse (LPN) was not notified that the resident had eaten before being sent to the hospital. The facility lacked a policy and procedure to guide staff on notifying dietary and nursing personnel about NPO orders, and there was no evidence that the 24-hour report conveyed the resident's NPO status.
Deficient Training Program for Agency Staff
Penalty
Summary
The facility failed to develop, implement, and maintain an effective training program for contracted staff, which was consistent with their expected roles and the necessary types of training. This deficiency was identified through interviews and record reviews, revealing that none of the six agency staff interviewed received adequate orientation or training. The facility did not have a policy or procedure in place for the required training of agency staff, and the orientation process was inconsistent and informal, relying on verbal instructions and brief tours. A resident expressed concerns about the lack of training among agency staff, particularly on the third shift, which affected their care routine, such as the timing and process for dialysis preparation. The resident noted that agency staff did not adhere to the expected protocols, such as writing their names on the whiteboard, which contributed to their frustration. The surveyor's interviews with agency staff confirmed the absence of a structured orientation process, with some staff receiving only a brief tour and verbal instructions from the outgoing shift nurse. The facility's staffing coordinator and DON acknowledged the lack of a formal orientation program for agency staff, with the orientation process being largely dependent on the unit managers and the supervisor on duty. An orientation checklist was introduced only recently, and there was no existing policy for agency staff orientation at the time of the survey. The inconsistency in the orientation process and the absence of a formal training program for agency staff were significant factors contributing to the deficiency identified by the surveyors.
Failure to Provide Scheduled Showers to Residents
Penalty
Summary
The facility failed to ensure that two residents, R402 and R404, who were unable to perform activities of daily living independently, received the necessary services to maintain good hygiene. Both residents were scheduled to receive showers weekly, but neither received them according to their schedules. R402, who requires maximum assistance with bathing and has fully intact cognitive function, reported not having a shower or bath in the last month and indicated no refusal of care. The facility's records showed a single entry of refusal for R402, with no other documentation of bathing activities for the past 30 days. Similarly, R404, who also requires maximum assistance with bathing and has fully intact cognitive function, reported not having been offered a shower in the last month. The records for R404 indicated only two bed baths and one instance of the resident not being available, with no other entries for bathing activities. Despite inquiries, the Director of Nursing and the Nursing Home Administrator could not provide additional information on why the showers were not provided, highlighting a deficiency in the facility's adherence to its policy on maintaining residents' hygiene.
Failure to Adhere to Pressure Ulcer Prevention Plan
Penalty
Summary
The facility failed to provide necessary care and services to prevent and promote healing of pressure injuries for a resident identified as R405. R405, who was admitted with conditions including paraplegia, severe protein-calorie malnutrition, and end-stage renal disease, was at risk for developing pressure ulcers. The care plan for R405 included the use of off-loading boots to prevent pressure injuries, with specific instructions for different types of boots to be worn at different times of the day. Despite these instructions being clearly posted in the resident's room, the surveyor observed multiple instances where R405 was not wearing the prescribed off-loading boots while in bed. During the survey, it was noted that the CNAs assisting R405 were unaware of the specific boot schedule and did not initially notice the sign in the resident's room. This lack of awareness led to R405 not having the appropriate boots on as per the care plan. The CNAs had to refer to the care plan and were only made aware of the sign after it was pointed out by the surveyor. This indicates a failure in communication and adherence to the care plan, resulting in the deficiency noted by the surveyor.
Failure to Notify Provider of Resident's Change in Condition
Penalty
Summary
The facility failed to ensure that a resident experiencing a change of condition received treatment and care in accordance with professional standards of practice. The resident, who had a history of recurrent urinary tract infections (UTIs) and sepsis, was prescribed Prednisone for neck inflammation without an end date. The resident received a high dose of Prednisone from September 12, 2023, through September 29, 2023, when a taper was ordered. The resident was hospitalized with sepsis and a UTI, and hospital documentation indicated a possible element of adrenal insufficiency due to the prolonged high dose of Prednisone. Additionally, the resident experienced low blood pressure readings on October 1 and October 2, 2023, but no provider was notified. The resident had an active order for Midodrine, a medication to help with low blood pressure, which was not administered as ordered on these dates. The facility's failure to notify a provider of the resident's low blood pressure and missed doses of Midodrine contributed to the resident's unstable condition, leading to hospitalization in the ICU with sepsis and UTI. The facility's policies required prompt notification of changes in a resident's condition, including significant changes in physical status. However, the facility did not follow these policies, as evidenced by the lack of a care plan addressing the resident's risk for infection due to recurrent UTIs with sepsis and hypotension. The surveyor noted that the facility's process for entering readmission orders was not followed, resulting in the omission of a stop date or tapered dosing for Prednisone. The failure to identify a change in condition and consult with a provider timely created a finding of immediate jeopardy.
Removal Plan
- R35 was evaluated for any noted change in condition to include evaluation of vital signs.
- R35 had R35's medications reviewed to ensure provider call parameters are in place.
- Residents residing in the facility were evaluated for any noted change in condition to include evaluation of vital signs.
- Nursing staff will be educated on the facility notification of change policy to include provider notification and RN assessment and will complete a test to validate competency.
- All staff will be educated on proper reporting of any noted changes in condition.
- Licensed nursing staff will be educated on appropriate documentation for changes in condition.
- Licensed nursing staff will be educated on the facility policy regarding medication reconciliation and administration.
- Licensed nursing staff and CNAs; including agency will receive the above re-education.
- A daily audit during clinical standup will be conducted to monitor for any changes in condition to include vital signs. This audit will be conducted for one month.
- Results of audits/monitoring will be provided to QAPI, which may further modify audit expectations based on results of initial audits.
- AD HOC QAPI meeting - The QAPI Committee to review the alleged deficiency, discuss above action items and planned audits related to findings.
Failure to Provide Adequate Pressure Ulcer Care
Penalty
Summary
The facility failed to provide necessary treatment and services consistent with professional standards of practice for residents with pressure injuries, leading to the development and worsening of pressure ulcers in three residents. One resident, who was admitted with multiple comorbidities including a femur fracture and multiple sclerosis, developed a stage 4 pressure injury to the sacrum and a stage 3 to the left buttock. The facility did not complete a Braden Scale Evaluation until the pressure ulcer was discovered, indicating a high risk for pressure ulcer development. The resident did not receive an air mattress until 12 days after admission and 7 days after the development of the pressure ulcer, and no comprehensive care plan was created to address the risk of pressure ulcers. Another resident was observed with an air mattress set incorrectly at 660 pounds, despite weighing only 123.8 pounds. This resident had three stage 3 pressure injuries, and the incorrect mattress setting was noted over multiple days. The facility staff failed to adjust the mattress setting appropriately, which could have contributed to the lack of improvement in the resident's pressure injuries. A third resident was admitted with multiple wounds, including a stage 3 pressure injury and several unstageable pressure injuries. However, the facility did not document comprehensive assessments, measurements, or staging of these wounds upon admission. It was not until later that the wounds were documented and measured, indicating a lack of timely and appropriate wound care management. The facility's documentation inconsistencies and delayed assessments contributed to the inadequate care provided to this resident.
Removal Plan
- A comprehensive wound evaluation completed
- Braden completed
- New treatment orders obtained
- Foley initiated to aid in healing
- Care plan initiated including LAL mattress
- COC completed with MD notification
- Clinical leadership and RD met, reviewed and revised CP
- A full house skin sweep was completed
- Braden's re-evaluated
- A full-time wound nurse has been hired and started
- Licensed nursing staff education on skin and wound policy to include what to do when a new wound is found, weekly skin check, what to do if there is a change in a wound and validated with a test initiated
- Certified nursing assistants' education on skin and wound policy to include what to do when a new wound is found, how to communicate changes in conditions and validated with a test initiated
- Risk meetings were initiated
- Quality monitor introduction
- CMS Meta Star training is scheduled
- An audit of weekly skin will be completed during clinical stand up
Failure to Prevent Accidents and Provide Adequate Supervision
Penalty
Summary
The facility failed to provide adequate supervision and interventions to prevent accidents for five residents, leading to significant harm. One resident, identified as R167, was admitted with multiple diagnoses including dementia and a history of falls. Despite being assessed as high risk for falls, the facility did not update the resident's care plan with individualized interventions such as keeping the bed in the lowest position or using a floor mat. This oversight resulted in an unwitnessed fall, leading to a left femoral neck fracture and subsequent surgical intervention. The resident developed post-surgical complications and was transferred to hospice care, where they later expired. Another resident, R83, experienced a staff-assisted fall due to the failure of CNAs to use a mechanical lift as required by the care plan. Instead, they attempted to transfer the resident using a gait belt, resulting in a fall and a fractured right ankle. The incident was not reported to the nurse immediately, delaying appropriate medical assessment and intervention. The CNAs involved were not suspended immediately, and the incident was not investigated promptly, indicating a lack of adherence to facility protocols. Additionally, resident R35, who was assessed as high risk for falls, experienced a fall without injury. However, the facility did not conduct a fall investigation to determine the root cause or ensure that fall interventions were appropriate and in place. This lack of investigation and documentation highlights a systemic issue in the facility's approach to fall risk management and accident prevention.
Removal Plan
- Reviewed residents fall risk care plan to ensure individualized interventions in place as needed.
- Reviewed with therapy resident transfer status with care plan revisions as needed.
- Care plans reviewed for mechanical sling lifts to include sling size.
- Review of post fall meeting and new process put into place to include review of chart and full IDT review.
- A weekly risk meeting will be initiated and completed weekly ongoing.
- Quality monitor introduction.
- Fall education for licensed nurses and CNAs.
- Review of trending fall report. Staffing allocation reviewed for the facility.
- Transfer competencies.
- Additional lifts rented for the facility.
- An audit will be completed daily during clinical stand up to complete Interdisciplinary Team (IDT) review.
- A member of the governing body will review the plan on a weekly and as needed basis until substantial compliance has been achieved.
Failure to Address Allegation of Neglect and Verbal Abuse
Penalty
Summary
The facility failed to ensure the safety of its residents by not properly addressing an allegation of neglect and verbal abuse involving a resident. The incident involved two CNAs who transferred a resident without using the required mechanical lift, resulting in the resident falling and fracturing her right ankle. The CNAs did not report the fall to the nurse on duty until several hours later, and one of the CNAs was heard making a derogatory comment to the resident during the transfer, causing the resident anxiety. The resident, who was moderately cognitively impaired and dependent on assistance for transfers, was admitted with a history of weakness and falls. Despite the care plan indicating the need for a mechanical lift with two-person assistance, the CNAs attempted to transfer the resident using a gait belt. After the fall, the resident was assisted into her wheelchair and attended an activity without immediate medical evaluation. The incident was not reported to the Nursing Home Administrator until the following day, delaying the start of an investigation. The facility's policy on abuse, neglect, and exploitation requires immediate investigation and protection of residents from harm. However, the CNAs involved were not suspended pending investigation, and there was no evidence of an investigation being initiated on the day of the incident. The failure to promptly address the incident and the verbal abuse allegation had the potential to affect all residents in the facility.
Improper Disposal of Garbage and Refuse
Penalty
Summary
The facility failed to ensure proper disposal of garbage and refuse in the outside garbage storage receptacles, which had the potential to affect all 115 residents. Over the course of three consecutive days, the surveyor observed the facility's dumpster overflowing with refuse, with additional garbage bags placed on the ground next to the receptacle. Swarms of flies were noted surrounding the outside garbage storage area, indicating unsanitary conditions. During an interview, the Nursing Home Administrator (NHA) acknowledged the issue, attributing it to challenges in getting the facility's garbage picked up due to a recent change of ownership. The problem had persisted for approximately three weeks, and no additional information was provided by the facility at the time of the survey.
Infection Preventionist Lacks Specialized Training
Penalty
Summary
The facility failed to ensure that the designated Infection Preventionist (IP) had completed specialized training in infection prevention and control. The Director of Nursing (DON-B) assumed the role of the IP after the previous IP left the position without notice. During an interview, DON-B confirmed that they had not yet completed the necessary training modules provided by the Centers for Disease Control and Prevention (CDC). This lack of specialized training for the acting IP had the potential to affect all 115 residents in the facility. The Nursing Home Administrator (NHA-A) was informed of this concern, but no additional information was provided by the facility at the time of the survey.
Lack of Performance Reviews for CNAs
Penalty
Summary
The facility failed to ensure that five Certified Nursing Assistants (CNAs) had documented performance reviews, despite being employed for over a year. This deficiency was identified during an interview and record review, which revealed that CNAs identified as CC, DD, EE, FF, and GG did not have performance evaluations on file. The facility's policy, dated May 2, 2023, mandates annual evaluations for all employees to comply with federal regulations. On July 15, 2024, the Nursing Home Administrator (NHA) acknowledged the absence of these evaluations and confirmed that they should be conducted at least yearly. The lack of performance reviews for these CNAs has the potential to impact all 115 residents in the facility who may receive care from them. No additional information was provided to explain why the evaluations were not completed.
Failure to Provide Required Transfer Notices
Penalty
Summary
The facility failed to provide the required written notification to residents and their representatives regarding transfers to the hospital, as observed in seven cases. The facility's policy mandates that transfer notices include specific information such as the reason for transfer, effective date, location, appeal rights, and contact details for the State Agency, Ombudsman, and Disability Rights agency. However, the surveyor found that the forms used by the facility lacked this essential information. In the case of a resident who was cognitively intact, the surveyor noted that the facility did not provide the necessary transfer notice with complete contact information. Despite requests for evidence, the facility only provided forms that were missing the required details. Similarly, another resident with severe cognitive impairment and an activated Power of Attorney for Healthcare was transferred without the proper notification being given to their representative. Other residents, including those with complex medical conditions such as acute respiratory failure, chronic obstructive pulmonary disease, and quadriplegia, were also transferred without receiving the appropriate notices. The surveyor repeatedly requested documentation from the facility, but the facility was unable to provide evidence that the required transfer notices were given. This lack of compliance with notification requirements was consistent across all reviewed cases, indicating a systemic issue within the facility.
Failure to Provide Bed Hold Notices During Resident Transfers
Penalty
Summary
The facility failed to provide written bed hold notices to residents or their representatives during transfers to hospitals or therapeutic leaves, as required by regulations. This deficiency was identified for four residents during a survey. The facility's policy mandates that residents or their legal representatives receive written information about the bed hold policy at admission, in advance of any transfer, and at the time of transfer. However, the survey revealed that this policy was not followed for residents R31, R40, R35, and R59. Resident R31, who was admitted with multiple serious health conditions, was transferred to the hospital due to a change in condition. Despite the facility's use of a transfer form, there was no evidence that a bed hold notice was provided to R31 or their representative. Similarly, resident R40, with a history of acute embolism and other health issues, was transferred to the ER and subsequently admitted to the hospital. The facility was unable to provide documentation of a bed hold notice for this resident. Resident R35, who has multiple sclerosis and other significant health issues, was hospitalized four times, yet no bed hold notices were documented for any of these hospitalizations. Lastly, resident R59, with chronic respiratory failure and other conditions, was hospitalized for a period, but again, no bed hold notice was found in the records. The surveyor's inquiries to the Nursing Home Administrator and Director of Nursing confirmed the absence of these notices, highlighting a systemic issue in the facility's adherence to bed hold notification requirements.
Medication Labeling and Storage Deficiency
Penalty
Summary
The facility failed to ensure that medications were labeled and stored according to their policy and procedures, as observed during a survey. Specifically, two out of four medication carts reviewed contained medications without proper labeling, such as missing open dates. On the first floor medication cart, four ophthalmic medications and one liquid medication were found without names or open dates, and one expired stock medication was noted. Similarly, on the second floor medication cart, two ophthalmic medications lacked names or open dates, and two expired stock medications were found. Additionally, six expired medications were discovered in the first floor medication room. During the survey, specific instances were noted, including a lantus insulin for a resident on the 200 unit medication cart that was not marked with an open date. On the 300 unit medication carts, lantanoprost eye drops for two residents and a deep sea nasal moisture spray for another resident were found open without listed open dates. The Nursing Home Administrator was informed of these concerns, but no additional information was provided to explain why the facility did not adhere to its medication storage policy.
Infection Control Deficiencies in PPE Use and Linen Management
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by multiple observations of staff not adhering to proper PPE protocols for residents with confirmed or suspected infections. A resident, who tested positive for COVID-19, was not consistently managed with appropriate PPE by staff. The surveyor observed that the isolation cart outside the resident's room lacked gowns, and staff were seen without masks or wearing them improperly. Additionally, there was no designated bin for disposing of PPE, and staff did not consistently sanitize their hands after leaving the resident's room. Another resident, suspected of having Clostridium Difficile, was not placed under contact precautions in a timely manner. The surveyor noted the absence of an isolation sign on the resident's door, and it was only after a positive stool sample was confirmed that contact isolation was initiated. The delay in implementing isolation measures indicates a lapse in the facility's infection control practices. Furthermore, the facility's 300 unit linen cart was repeatedly observed without a protective covering, contrary to the facility's policy that linen carts should be covered when not in use. This oversight was acknowledged by the Director of Nursing, yet no additional information was provided to explain the failure to maintain proper infection control standards in this regard.
Failure to Protect Resident from Abuse and Neglect
Penalty
Summary
The facility failed to protect a resident from verbal abuse and neglect, resulting in a fracture. The resident, who was moderately impaired and dependent on mechanical lift transfers, was transferred by two CNAs without the required equipment, leading to a fall and a fractured ankle. The CNAs were aware of the need for a mechanical lift but chose to use a gait belt instead. After the fall, the CNAs did not immediately report the incident to the nurse on duty, delaying medical evaluation and treatment. During the transfer, one of the CNAs verbally abused the resident, causing emotional distress. The verbal abuse was not reported to the nurse by the other CNA, further neglecting the resident's well-being. The incident was not reported to the nursing home administrator until the following day, and the involved CNAs were not suspended immediately, allowing them to complete their shifts. The facility's investigation substantiated the neglect and verbal abuse allegations. The resident experienced increased pain and emotional distress following the incident, requiring medical intervention and pain management. The facility's policy on abuse and neglect was not followed, as the incident was not immediately investigated or reported to the appropriate authorities.
Delayed Reporting of Abuse Allegations
Penalty
Summary
The facility failed to immediately report two allegations of abuse involving residents R83 and R34 to the appropriate authorities and did not complete the required investigation within the mandated timeframe. In the case of R83, the resident was transferred without a mechanical lift, resulting in a fall and a fractured ankle. During the incident, a CNA made a derogatory remark to R83, which was not reported to the Nursing Home Administrator (NHA) or the Licensed Practical Nurse (LPN) on duty at the time. The incident was only reported to the NHA the following day, and the verbal abuse was not reported to the state agency within the required two-hour window. For R34, the facility did not submit the results of an abuse investigation to the State Survey Agency within the required five business days. R34 reported that an LPN was rude and shook their fist at them, which was initially reported to the state agency. However, due to a change of ownership and issues accessing the facility's system, the required documentation was submitted four days late. The new NHA submitted the report as soon as they had access, but it was still outside the mandated timeframe. The facility's policy on abuse, neglect, and exploitation requires immediate reporting of all alleged violations to the Administrator and relevant agencies. However, in both cases, the facility failed to adhere to these policies, resulting in delayed reporting and investigation of the incidents. The lack of immediate action and communication among staff members contributed to the deficiencies noted in the report.
Deficiencies in ADL Assistance and Hygiene
Penalty
Summary
The facility failed to provide necessary services for residents who were unable to carry out activities of daily living, resulting in deficiencies in nutrition, grooming, and personal hygiene. Resident R229, who has multiple diagnoses including Parkinsonism and diabetes, was not properly set up for meals and was left in a wet bed for over four hours. Observations revealed that R229's meal trays were not delivered in a timely manner, and the resident was not positioned upright to eat, leading to missed meals. Additionally, documentation of meal consumption was found to be inaccurate and incomplete. Resident R15, who has a history of multiple health issues including morbid obesity and diabetes, reported not having received a shower or bath in four weeks. The facility's records did not show evidence of showers being provided, and there was no documentation of refusal. The care plan indicated that R15 required assistance with bathing, but the facility failed to ensure that this was carried out according to the resident's needs and preferences. Resident R64, diagnosed with a neurocognitive disorder and traumatic brain injury, was observed with long and dirty fingernails over several days. Despite having a care plan that required weekly nail care, the facility did not provide the necessary grooming services. The resident's documentation indicated that a full bed bath was given, but nail care was not performed, leaving the resident with untrimmed and unclean nails.
Failure to Provide Individualized Activities Program for Resident
Penalty
Summary
The facility failed to provide an ongoing, individualized, and meaningful activities program for a resident, identified as R11, who was reviewed for activities. R11, who is bed-bound and legally blind, reported feeling bored with nothing to do but watch TV in their room. The facility did not complete an assessment of activity goals for R11, and no plan of care related to activities was developed. The facility's policy requires that each resident's interests and needs be assessed routinely, and activities should be designed to enhance well-being and reflect the resident's interests and preferences. R11 was admitted to the facility with multiple diagnoses, including multiple sclerosis, a fracture of the neck of the right femur, muscle weakness, unspecified dementia, neuromuscular dysfunction of the bladder, and legal blindness. The Minimum Data Set (MDS) assessment indicated severe cognitive impairment and highly impaired vision. Despite these conditions, the facility did not conduct an activity assessment to understand R11's preferences or goals. The surveyor noted that the facility's activity staff occasionally offered mobile carts with puzzles, books, games, and crafts, but these were not suitable for R11's condition. Additionally, there were no audio books available, and the staff did not document whether activities were offered and refused. The surveyor found that R11's plan of care lacked any information related to activities, indicating a failure to provide individualized and meaningful activities for R11. The facility's activity evaluation forms, which should have been completed within four days of admission and during subsequent assessments, were found to be incomplete. The surveyor shared these concerns with the facility consultants, who acknowledged the lack of an activity assessment and plan of care for R11. No additional information was provided to explain why the facility did not meet the requirements for an individualized activities program for R11.
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Surveyors found that the facility’s Water Management Plan (WMP) and infection control program did not identify or manage all high‑risk plumbing fixtures, including unused in‑room showers, capped stand‑up shower fixtures, and handheld shower fixtures on a rehab hallway. A resident reported their in‑room shower did not work and had not been used, and surveyors observed the shower filled with personal belongings, thick soap scum, and no signs of recent water use. The NHA and Maintenance Director confirmed that two in‑room showers had not been used for years, that multiple unused or capped fixtures were not included in the WMP, and that these fixtures were not being flushed. Although the Maintenance Director stated that an activity sink and bathtub were flushed weekly, there was no documentation to verify these activities, and the WMP lacked identification and control measures for these high‑risk areas.
Two residents were physically abused by peers when the facility failed to prevent resident-to-resident altercations. In one case, a cognitively intact wheelchair user was grabbed by another cognitively intact wheelchair user and flipped backward out of his chair after a verbal dispute, as observed by an LPN who heard a commotion and then saw the resident on the floor. In another case, a cognitively impaired resident with a history of physical assault and a care plan calling for separation from aggressors and staff presence during activities was struck in the face multiple times by a peer with known impulsive and aggressive behaviors during a supervised group activity, resulting in swelling and redness to the head and face. These events occurred despite existing care plans and a facility policy intended to prohibit and prevent abuse.
Surveyors found that the facility did not update care plans for two residents to reflect significant changes in their needs and arrangements. For one resident, after a family member was barred from visiting following a police-involved incident, the care plan did not address how the resident would maintain communication with that family member despite staff discussing alternative contact methods. For another resident with bipolar disorder, traumatic brain injury, a court-appointed guardian, and an elopement history, the care plan documented that the resident could not leave independently but was not revised to include guardian-approved, escorted trips to a soup kitchen several times per week.
A cognitively intact resident with chronic pain related to systemic lupus erythematosus, care planned to receive scheduled Oxycodone, was mistakenly given Norco by an LPN during a night medication pass. The wrong narcotic was administered instead of the ordered Oxycodone, and the resident later reported receiving another resident’s medication and experiencing symptoms such as upset stomach, nausea, and extreme drowsiness for several hours. Facility documentation and interviews confirmed that the six rights of medication administration, including proper resident identification as required by policy, were not followed.
A resident with bipolar disorder, traumatic brain injury, a court‑appointed guardian, and a documented history of elopement was care planned as not permitted to leave independently, with hourly checks and a requirement for staff escort and prior guardian approval for exits. On one morning, an LPN observed the resident standing in the doorway, was told the resident was going to the store alone, confirmed there was no sign‑out, but did not verify guardian consent or prevent the resident from leaving. The resident then called a cab and left the building without supervision or guardian approval. The facility later discovered the elopement during hourly checks. Interviews confirmed that the care plan lacked specific, written parameters for the resident’s approved trips to a soup kitchen and did not clearly define when and how the resident could leave with permission, despite facility policy requiring person‑centered elopement care planning and adequate supervision.
Surveyors found that several residents’ rooms and bathrooms were not maintained in a sanitary, comfortable, and homelike condition. One resident’s shower contained a tan/gray/green chalky substance, scattered personal belongings, and an unmarked cup with green pellets, while the same room and an adjacent room had discolored ceilings and nearby water-damaged areas. Two residents shared a bathroom where the shower floor had rust-colored staining and a cardboard box with belongings scattered on the floor. In two other private bathrooms, surveyors observed bulging drywall, wall deterioration, and a large hole with exposed brick beneath wall-mounted toilets; leadership and the MD confirmed the damage, and one resident reported being upset that a previously reported hole had not been repaired.
A resident with a stage 4 pressure injury on the right lateral lumbar region did not receive wound care consistent with aseptic technique and facility policy. An LPN placed scissors and wound supplies on a PPE cart and an uncleansed bedside table, then used the same scissors to cut silver alginate that was applied directly to the wound bed. The LPN also sprayed gauze with wound cleanser and set the wet gauze on the outside of its package, which had contacted soiled surfaces, before using it in the wound care process. The DON acknowledged that these actions could contaminate the wound and were not in accordance with the facility’s pressure injury prevention and management policy requiring evidence-based treatment to promote healing and prevent infection.
A resident receiving IV Ertapenem via a midline catheter had no care plan intervention for IV site monitoring and no physician order for normal saline (NS) flushes, yet an LPN flushed the midline with NS before and after an antibiotic infusion as a routine practice. The TAR contained an order for weekly PICC dressing changes, which the DON documented as completed, but the resident actually had a midline catheter. The DON initially reported a measurable external catheter length inconsistent with the hospital placement record, which documented a midline with 0 cm external length, and only later acknowledged that no external catheter or hash marks were visible, demonstrating inaccurate assessment and documentation of the midline catheter.
A non-employee visitor, the son of a cook, was allowed into the kitchen and was shown in a publicly accessible social media post actively assisting with kitchen duties, including handling beverage pitchers. The facility’s handbook requires employees to complete TB testing, orientation, and personnel file documentation, and specifies that visitors must enter through reception, be directed or escorted, and that employees are responsible for their visitors’ conduct. The Dietary Manager acknowledged the son was not an employee or volunteer and stated visitors were allowed only to visit in the back of the kitchen and were not permitted to touch food, yet the photo evidence confirmed the visitor was performing food service tasks, demonstrating that food and nutrition service functions were not limited to appropriately trained and authorized staff.
A resident’s right to a safe, clean, and comfortable environment was not honored when water-damaged ceiling tiles above the bed and doorway remained in place for an extended period after repeated leaks. The resident reported multiple times to the DON and maintenance about stained ceiling tiles and concerns about ceiling integrity and possible organic growth, but the tiles were not promptly removed or replaced despite maintenance staff acknowledging awareness of the issue and having replacement tiles available. The Maintenance Director stated he only recently became aware of the problem when the resident pointed it out, while another long-term maintenance staff member confirmed the damage had been present for about two weeks following an upstairs toilet overflow.
Failure to Implement Effective Water Management and Infection Control for Unused Plumbing Fixtures
Penalty
Summary
The deficiency involves the facility’s failure to establish and maintain an effective infection prevention and control program through an adequate Water Management Plan (WMP). The written WMP policy stated that a water management team, including facility leadership, the Infection Preventionist, maintenance, safety, risk/quality staff, and the DON, would develop and implement the program, maintain documentation of the water system, identify control points, apply control measures, verify implementation, update the plan as needed, and maintain documentation. However, the facility’s WMP did not identify all high‑risk plumbing fixtures, did not identify all locations where Legionella could grow and spread, and did not specify where control measures should be applied. The Water System Infection Control Risk Assessment identified six shower heads and hoses, but only two showers were observed during the tour, and there was no documentation that unused fixtures were maintained according to the WMP policy. Surveyors observed that a resident’s in‑room walk‑in shower was nonfunctional, contained a box of personal belongings, and had thick soap scum with no evidence of recent water use; the resident reported that this shower did not work and had not been used, and that they showered in a shower room down the hall. The NHA stated that this shower and another in‑room shower had not been used for approximately five years. The Maintenance Director confirmed that these showers and other capped, unused stand‑up shower fixtures and handheld shower fixtures on the rehab hallway had not been flushed and that these unused fixtures were not identified in the WMP. The Maintenance Director reported flushing an activity sink and a bathtub weekly but was the only person doing so, and the facility lacked documentation to verify these flushing activities. The NHA acknowledged that the WMP did not include identification and control measures for high‑risk areas such as unused showers and capped or unused plumbing fixtures.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from physical abuse during resident-to-resident altercations. In the first incident, one cognitively intact resident who used a wheelchair for ambulation approached another cognitively intact, wheelchair-using resident and grabbed him by the shirt, flipping him backward out of his chair. A nurse at the nurses’ station heard a commotion, saw the aggressor put his hand in front of the other resident’s face, and then observed the resident on the floor. The aggressor later stated he was tired of how the other resident was talking to everyone. The facility’s abuse/neglect/exploitation policy states it will provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, but the incident still occurred. In the second incident, a resident with non-traumatic brain dysfunction, anxiety, depression, and severely impaired cognition was physically assaulted by another resident during a supervised group activity. The assaulted resident’s care plan identified a focus area of having experienced physical assault, with risk for emotional trauma, fear, and behavioral change, and included interventions such as ensuring separation from the aggressor, avoiding seating near triggering individuals, and providing staff presence during group activities. During the group activity, the aggressor became acutely agitated and threatened the cognitively impaired resident with violence. Multiple staff members reported that the aggressor cursed, tried to get to the resident, maneuvered past staff, came around the table, and struck the resident in the face multiple times. Clinical documentation following the second incident described that the assaulted resident was struck with a closed fist on the right side of the face and head, with swelling and redness noted above and in front of the temple area and under the right eye. The aggressor’s care plan, in place prior to the incident, documented that he became easily irritated and frustrated when peers joked or made comments, exhibited impulse-driven behaviors including taking food from peers and becoming physically aggressive when they resisted, and had repeated involvement in resident-to-resident altercations placing himself and others at risk for physical injury. Interventions on his care plan included monitoring social interactions, providing education on coping strategies, reinforcing positive behaviors, increasing observation during mealtimes, seating to minimize conflict and opportunity for taking others’ items, and redirecting him away from peers at early signs of agitation. Despite these identified risks and planned interventions, the resident was able to escalate and physically assault another resident during the group activity.
Failure to Revise Care Plans for Family Communication and Supervised Community Outings
Penalty
Summary
The deficiency involves the facility’s failure to revise and individualize care plans to reflect changing resident needs and circumstances. For one resident with intact cognition and no documented behaviors, the record shows that a family member was escorted from the facility by local police after suspected drug use and making physical threats against the DON, resulting in the family member being unable to visit. The SSD met with the resident to assess for psychosocial impact and encouraged the resident to maintain contact with the family member through alternative means. However, the resident’s care plan, initiated in 2021 and last revised in April 2026, did not address how the resident would maintain communication with this family member who could no longer enter the facility. The Administrator, SSD, and ADON all confirmed that the care plan did not include this issue or any related interventions. A second resident, also cognitively intact and diagnosed with bipolar disorder and a traumatic brain injury, had a court-ordered guardian and was care planned as not permitted to leave the facility independently due to elopement risk and impaired judgment. An elopement report documented that this resident had previously called a taxicab and left the facility to go to a soup kitchen without the guardian’s consent. After this incident, the guardian approved planned outings to the soup kitchen with a facility escort who would remain with the resident during the outing. Despite this change, the resident’s care plan, which addressed elopement risk and the restriction on independent leaving, was not updated to include the guardian-approved outings to the soup kitchen or the intervention of a facility escort accompanying the resident. The SSD and ADON confirmed that these arrangements were not reflected in the resident’s care plan.
Failure to Follow Resident Identification and Six Rights During Medication Administration
Penalty
Summary
The deficiency involves a failure to follow professional standards for medication administration, specifically proper resident identification and adherence to the six rights of medication administration. A cognitively intact resident with systemic lupus erythematosus, who received scheduled and PRN pain medications for occasional moderate pain, was care planned to receive pain medications as ordered. On the date in question, the resident was scheduled to receive Oxycodone 5 mg at 3:00 AM. Instead, the night-shift LPN administered Hydrocodone/APAP (Norco) 5/325 mg. The facility’s incident documentation stated that the resident usually received scheduled Oxycodone 5 mg three times daily and that the wrong medication was given at the 3:00 AM dose. The facility’s policies required identification of the resident by photo in the MAR and verification of the right resident as part of the six rights of medication administration. The incident audit and interviews confirmed that the six rights of medication administration were not followed. The resident later filed a grievance stating they were given the wrong medication on that date and reported receiving another resident’s medication at approximately 5:13 AM, a time when they usually received medication. The incident report documented that the resident was unaware of the error until notified by the floor nurse and did not reflect that the resident experienced upset stomach, nausea, and extreme drowsiness for several hours. The facility’s Medication Administration and Medication Errors policies required medications to be administered according to the physician’s orders and in accordance with accepted standards and principles, including verifying the right resident, which did not occur in this case.
Failure to Implement Effective Elopement Prevention for a Resident Under Guardianship
Penalty
Summary
The deficiency involves the facility’s failure to implement effective interventions to prevent the elopement of a resident with a court‑appointed guardian who was not permitted to leave independently. The resident had diagnoses including bipolar disorder and traumatic brain injury and a BIMS score of 15/15, indicating intact cognition, but was identified in the care plan as being at risk for elopement due to impaired judgment and unsafe decision‑making. The care plan, initiated months earlier, documented that the resident had a court‑ordered guardian and was not allowed to leave the facility independently, with a goal of no elopement incidents and interventions including hourly checks and a requirement that all exits from the building required a staff escort and prior guardian approval. On the date of the elopement, the resident called a taxicab and left the facility to go to a soup kitchen without the guardian’s consent. A progress note documented that earlier that morning an LPN observed the resident standing in the entranceway and doorway of the building and, upon asking where the resident was going, was told the resident was going to the store. The LPN acknowledged knowing the resident was leaving by herself, did not verify guardian approval, and did not prevent the resident from leaving. The LPN reported asking the DON about signing the resident out, and both checked the sign‑out book and saw there was no entry, but the resident was still allowed to leave. The facility only became aware that the resident had eloped and gotten into a cab when staff realized during hourly checks that she was no longer in the building. Record review showed that the resident had a documented history of elopement at home and ongoing exit‑seeking behaviors, including episodes of agitation and attempts to leave the facility unsupervised. Interviews with the SSD and ADON confirmed that, despite the resident’s known elopement risk and the guardian’s control over outings, the care plan did not contain specific interventions or parameters for the resident’s trips to the soup kitchen or other outings, nor did it clearly outline the circumstances under which the resident could leave with permission. The facility’s elopement policy required person‑centered care planning, adequate supervision, and monitoring of interventions for residents at risk of elopement, but the documented care plan and staff actions did not prevent the resident from leaving the building without guardian approval or staff escort, resulting in an elopement event.
Failure to Maintain Sanitary and Well-Maintained Resident Rooms and Bathrooms
Penalty
Summary
The deficiency involves the facility’s failure to maintain a sanitary, comfortable, and homelike environment in multiple resident rooms and bathrooms. Surveyor observations with the NHA and MD revealed that one resident’s shared bathroom shower contained a tan/gray/green chalky substance on the walls, a cardboard box of personal belongings scattered on the shower floor, and an unmarked plastic cup with green cylindrical pellets placed on top of the shower. The same resident’s room had brown discoloration in a ceiling corner and a deteriorating area of water-damaged plaster and trim behind the door, which the NHA stated was related to a previous roof issue and that the shower had not been used for at least five years. Similar brown discoloration was observed in the ceiling corner of an adjacent resident’s room and a sagging, water-damaged ceiling tile in the hallway outside these rooms. Additional observations showed that two other residents’ shared bathroom shower had a rust-colored substance and stains on the shower floor, along with a cardboard box of personal belongings and items scattered on the shower floor. One resident’s private bathroom had bulging drywall and deterioration on the wall below the wall-mounted toilet, and another resident’s bathroom had a hole approximately one foot by one foot with exposed brick and wall material below the toilet. The NHA and DON verified the wall damage in these bathrooms but reported they were not previously aware of it, while one resident stated being upset that a family member had reported the hole and it had not been fixed. The MD acknowledged the damage in both bathrooms, noting possible prior moisture and that a plumber may have accessed the wall without notifying maintenance.
Improper Aseptic Technique During Pressure Ulcer Wound Care
Penalty
Summary
The deficiency involves the facility’s failure to provide appropriate, non-contaminated wound care for a resident with a stage 4 pressure injury on the right lateral lumbar region. The resident was cognitively intact and had a physician’s order directing that the wound be cleansed with wound cleanser or normal saline, skin prep applied to the peri-wound, followed by silver alginate to the wound base, covered with an ABD pad and secured with Hypafix tape, with dressing changes daily and as needed. During an observed wound care procedure, the LPN placed scissors, a 4x4 gauze package, and an ABD package on a PPE cart outside the resident’s room, then carried these items into the room and set them on an uncleansed bedside table. The LPN used the same scissors, which had been on the PPE cart and bedside table, to cut silver alginate that was then applied directly to the resident’s wound bed. The LPN further removed gauze from its package, sprayed it with wound cleanser, and placed the wet gauze on the outside of the gauze package that had already contacted the PPE cart and the uncleansed bedside table. After removing the resident’s soiled dressing, cleansing the wound, and applying skin prep, the LPN applied the silver alginate and ABD dressing and secured it with Hypafix tape. The LPN then placed the remaining silver alginate back into its original package and returned it to the drawer. The DON confirmed that placing scissors and supplies on the PPE cart and uncleansed bedside table, then using them on the wound, and placing wet gauze on a contaminated package could contaminate the wound, which was inconsistent with the facility’s Pressure Injury Prevention and Management policy requiring treatment and services to heal pressure injuries and prevent infection using evidence-based practices.
Unauthorized IV Flushes and Inaccurate Midline Catheter Assessment
Penalty
Summary
The deficiency involves the facility’s failure to ensure parenteral medications were administered according to a physician’s order and to accurately assess and document a resident’s midline catheter. A resident with intact cognition, admitted with diagnoses including UTI and ESBL infection, returned from the hospital with an IV catheter for continuation of IV Ertapenem therapy. The resident’s care plan noted IV antibiotic therapy but did not include an intervention to monitor the IV site. Facility policy required that medications be administered only upon a signed prescriber order and that PICC/midline/CVAD catheters be inspected and measured from hub to skin entry to detect migration. Surveyor review of the resident’s record showed a TAR order for weekly PICC dressing changes, which was documented as completed by the DON, but the record did not contain any order for normal saline (NS) flushes. During observation, an LPN prepared and administered Ertapenem via the resident’s catheter using a ball pump. Before starting the infusion, the LPN scrubbed the hub and flushed the catheter with 10 ml NS, then connected the antibiotic tubing and initiated the infusion. Later, after clamping the IV tubing, the LPN again scrubbed the hub and flushed the catheter with another 10 ml NS. When questioned, the LPN acknowledged there was no order for NS flushes in the medical record and stated that flushing before and after an infusion was routine practice. The DON reported having performed the resident’s catheter dressing change and stated that the external catheter length had been measured, but also stated there was no place in the record to document this measurement. The DON initially reported an external catheter length of 10 cm without the hub and 14 cm with the hub, and provided hospital placement documentation. Surveyor review of that documentation showed the device was a single-lumen power midline with an external catheter length of 0 cm. An RN from the infusion clinic confirmed the resident had a midline catheter, not a PICC, and that a midline’s external length should be 0 cm, with visible hash marks only if the catheter was migrating out. Upon being informed of this, the DON then stated there was 0 cm of external catheter visible and no hash marks seen during the dressing change, indicating the earlier measurement provided by the DON did not accurately reflect the midline catheter’s documented external length.
Untrained Visitor Allowed to Perform Kitchen Duties and Handle Beverages
Penalty
Summary
The deficiency involves the facility’s failure to ensure that dietary staff had appropriate competencies and that only qualified personnel carried out food and nutrition service functions. A cook’s son, who was not an employee or volunteer of the facility, was observed in a social media post assisting with kitchen duties, including handling beverage pitchers on a counter in the kitchen. The post, which remained publicly visible, included a caption from the cook thanking her son for coming to work with her to help her out. The Division of Quality Assurance received concerns about this situation and obtained photo evidence dated 03/30/26, showing the non-employee son in the facility kitchen handling beverages. Review of the facility’s employee handbook showed that employees are required to undergo a two-stage TB test upon hire, have a 6‑month orientation period, and have a personnel file with identifying information, health and training records, and reference checks. The handbook also states that all visitors should enter through reception, receive directions or be escorted, and that employees are responsible for the conduct and safety of their visitors. The Dietary Manager confirmed that the cook’s children were not employed or volunteering in the kitchen and stated that while the son sometimes visited his mother and was allowed in the back of the kitchen if wearing a hair net and staying near the exit door, visitors were not allowed to touch any food. The surveyor verified the kitchen location from the photo and confirmed with leadership that the social media posting showed the non-employee son actively working in the kitchen, which did not align with facility policies or competency and staffing requirements for food and nutrition services.
Failure to Timely Address Water-Damaged Ceiling in Resident Room
Penalty
Summary
The deficiency involves the facility’s failure to ensure a safe, clean, comfortable, and homelike environment for one resident whose room ceiling had visible water damage. Over the course of about a month, the resident reported multiple incidents of water leaking from the ceiling, resulting in brown-stained blotches above the bed and doorway. The resident stated these concerns were brought to the DON several times and also discussed with maintenance, and reported being told that maintenance was having difficulty obtaining replacement tiles. The resident expressed concern about the integrity of the ceiling and the presence of organic growth and wanted the damaged tiles removed. Interviews with facility staff revealed inconsistent awareness and delayed response to the water damage. The Maintenance Director, who was new to the role, reported that there had been no leaking pipes in the last month and attributed the damage to an overflowing toilet, stating that the day of the interview was the first time he became aware of the issue, after the resident pointed it out during a visit to the room. Another maintenance staff member, with 12 years of experience at the facility, stated he had known about the water damage for about two weeks following an upstairs toilet overflow and that new tiles were available but had not yet been installed, noting that caulk had been used in some previously damaged areas. The NHA and DON later stated the damage was from a recent leak and that the facility was waiting for the area to dry before replacing tiles, but no additional information was provided regarding the delay in addressing the resident’s ongoing concerns and the visible water-damaged ceiling tiles.
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